Failure to Prevent Significant Medication Error with Incorrect Depakote Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when Depakote was administered at an incorrect dose over multiple days. The resident was admitted with unspecified convulsions/epilepsy and had an active order dated 03/16/25 for Depakote Sprinkle Capsules 125 mg, 2 capsules by mouth three times a day. The resident’s MDS indicated severely impaired cognition, no behaviors, and no rejection of care, and she received scheduled anticonvulsant medications during the review period. The March electronic MAR showed that she received Depakote 125 mg, 2 capsules three times daily from 03/17/25 through 03/31/25, with one documented refusal on 03/28/25 at 9:00 PM. A medication error was later identified when the pharmacy notified the facility that the wrong Depakote dose had been dispensed. The Medication Error Report completed by the previous DON documented that the pharmacy had dispensed Depakote 500 mg, 2 capsules three times a day, while the active order was for Depakote 125 mg, 2 capsules three times a day. The report stated that the resident received the incorrect dose for 6 days. The investigation summary indicated that weekly Smartpass medication rolls were delivered on 03/27/25, and on 04/02/25 the pharmacy notified the facility that the wrong dosage had been dispensed for this resident. The previous DON verified that the active Depakote order on the MAR and the order printed on the Smartpass pouch were not the same. Nursing staff actions and inactions contributed to the continuation of the incorrect dosing. The previous DON stated that the pharmacy believed the error was related to nursing staff not using the medication scanner when preparing medications, and she acknowledged that she herself worked the medication cart on two nights and administered the incorrect Depakote dose without using the scanner or comparing the Smartpass pouch to the MAR. Multiple nurses and a medication aide who worked during the period when the incorrect dose was administered either did not recall the medication error or only recalled receiving general education on using scanners. Several nurses described their usual practice as scanning each Smartpass pouch and comparing it to the MAR, reading and comparing orders, and stated that if the dose had been different from the MAR they would have noticed it, but they could not explain how the incorrect dose was missed at the time. The DON and the attending physician both stated that nursing staff should have read and compared the medication on hand, including the Smartpass pouch, with the active MAR order to detect the discrepancy, and the physician noted that staff did not report any signs or symptoms of Depakote toxicity and that the resident may have refused medications at times without this being consistently documented on the MAR.
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